Wednesday, 4 July 2012

Surgical procedures Part 1

The vast majority of patients with symptom-causing hemorrhoids are able to be managed with non-surgical techniques. In the practice of a surgeon adept at managing hemorrhoids non-operatively, it is estimated that less than 10% of patients require surgery if the hemorrhoids are treated early.

Dilation: Forceful dilation of the anal sphincter by stretching the anal canal has been used to weaken the anal sphincter, the assumption being that the increased sphincter pressure is responsible for the hemorrhoids. Unfortunately, the dilation frequently damages the sphincter itself and many patients become incontinent or unable to control their stool after dilation. For this reason, dilation is rarely used to treat hemorrhoids.
Doppler ligation: Recently, the use of a special, illuminated anoscope with a Doppler probe that measures blood flow has enabled doctors to identify the individual artery that fills the hemorrhoidal vessels. The doctor then can tie off (ligate) the artery. This causes the hemorrhoid to shrink. The Doppler probe is expensive, and seems may offer little advantage over rubber band ligation.

Sphincterotomy: Occasionally, the internal portion of the anal sphincter is partially cut in an attempt to reduce the pressure of the sphincter within the anal canal. This procedure is rarely used alone, and there is concern about incontinence (loss of control) of stool as a potential complication.
Hemorrhoidectomy: Non-operative treatment is preferred because it is associated with less pain and fewer complications than operative treatment. Surgical removal of hemorrhoids (hemorrhoidectomy) usually is reserved for patients with third- or fourth-degree hemorrhoids.
During hemorrhoidectomy, the internal hemorrhoids and external hemorrhoids are cut out. The wounds left by the removal may be sutured (stitched) together (closed technique) or left open (open technique). The results with both techniques are similar. At times, a proctoplasty also is done. A proctoplasty extends the removal of tissue higher into the anal canal so that redundant or prolapsing anal lining also is removed.
Postsurgical pain is a major problem with hemorrhoidectomy. Potent pain medications (narcotics) usually are required. The addition of nonsteroidal antiinflammatory drugs (NSAIDs) such as ketorolac (Toradol), celecoxib (Celebrex), valdecoxib (Bextra) enhances the relief of pain, yet patients still do not return to work for 2-4 weeks.
Several other complications may occur following hemorrhoidectomy. Urinary retention (difficulty urinating) occurs in about 5% of patients. Although retention almost always is transient, it may require catheterization (insertion of a tube) to empty the bladder. Delayed bleeding or hemorrhage 7 to 14 days after surgery occurs in 1%-2% of patients. Narrowing of the anus due to scarring, formation of fissures, and infection (1% of patients) also may occur. Incontinence of stool (inability to control the passage of stool) is uncommon unless the anal sphincter is damaged. Finally, blood clots may form in external hemorrhoids following surgery if they are not removed.
Stapled hemorrhoidectomy: This is the newest surgical technique for treating hemorrhoids, and it has rapidly become the treatment of choice for third-degree hemorrhoids. Stapled hemorrhoidectomy is a misnomer since the surgery does not remove the hemorrhoids but, rather, the abnormally lax and expanded hemorrhoidal supporting tissue that has allowed the hemorrhoids to prolapse downward.
For stapled hemorrhoidectomy, a circular, hollow tube is inserted into the anal canal. Through this tube, a suture (a long thread) is placed, actually woven, circumferentially within the anal canal above the internal hemorrhoids. The ends of the suture are brought out of the anus through the hollow tube. The stapler (a disposable instrument with a circular stapling device at the end) is placed through the first hollow tube and the ends of the suture are pulled. Pulling the suture pulls the expanded hemorrhoidal supporting tissue into the jaws of the stapler. The hemorrhoidal cushions are pulled back up into their normal position within the anal canal. The stapler then is fired. When it fires, the stapler cuts off the circumferential ring of expanded hemorrhoidal tissue trapped within the stapler and at the same time staples together the upper and lower edges of the cut tissue.
Stapled hemorrhoidectomy, although it can be used to treat second degree hemorrhoids, usually is reserved for higher grades of hemorrhoids - third and fourth degree. If in addition to internal hemorrhoids there are small external hemorrhoids that are causing a problem, the external hemorrhoids may become less problematic after the stapled hemorrhoidectomy. Another alternative is to do a stapled hemorrhoidectomy and a simple excision of the external hemorrhoids. If the external hemorrhoids are large, a standard surgical hemorrhoidectomy may need to be done to remove both the internal and external hemorrhoids.

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